Center for Excellence in Assisted Living CEAL@UNC

Advancing the well-being of the people who live and work in assisted living through research, practice, and policy.

Academic Publication

Collecting, Sharing, and Using Information for Person-Centered Dementia Care: Perspectives of Residents, Care Partners, and Staff in Low-Resource Long-Term Care Settings

Aug 1, 2025
This study explored stakeholder perspectives on how information is collected, shared, and used to support person-centered dementia care in low-resource long-term care settings. This qualitative study was conducted in four long-term care settings situated in federally designated medically underserved areas (two rural, two urban). In-depth semi-structured interviews were conducted with administrative leaders (n = 7), […]

Collecting, Sharing, and Using Information for Person-Centered Dementia Care: Perspectives of Residents, Care Partners, and Staff in Low-Resource Long-Term Care Settings

by Lea Efird-Green

This study explored stakeholder perspectives on how information is collected, shared, and used to support person-centered dementia care in low-resource long-term care settings. This qualitative study was conducted in four long-term care settings situated in federally designated medically underserved areas (two rural, two urban). In-depth semi-structured interviews were conducted with administrative leaders (n = 7), […]

Daily Total Physical Activity and Hospitalization or Death in Older Adults in Assisted Living Residences: An Exploratory Cohort Study Using Two ActivPAL Accelerometers in Japan

Jul 1, 2025
Older adults in assisted living residences spend most of their time engaged in sedentary activities. However, the relationship between physical activity, sitting time, or lying time and hospitalization and mortality in older adults remains unclear. Therefore, the present study aimed to evaluate the relationship between physical activity and hospitalization or death among older adults in […]

Daily Total Physical Activity and Hospitalization or Death in Older Adults in Assisted Living Residences: An Exploratory Cohort Study Using Two ActivPAL Accelerometers in Japan

by Lea Efird-Green

Older adults in assisted living residences spend most of their time engaged in sedentary activities. However, the relationship between physical activity, sitting time, or lying time and hospitalization and mortality in older adults remains unclear. Therefore, the present study aimed to evaluate the relationship between physical activity and hospitalization or death among older adults in […]

Hospice Visits and Perceived Hospice Quality Among Assisted Living Residents

Jul 1, 2025
Background: Hospice services are widely used by assisted living residents at the end of life, yet concerns exist about the adequacy and quality of hospice care in this setting. Participants and setting: This cohort study analyzed Medicare claims data from 51,303 assisted living residents who received hospice care and died in 2018-2019. Data were linked […]

Hospice Visits and Perceived Hospice Quality Among Assisted Living Residents

by Lea Efird-Green

Background: Hospice services are widely used by assisted living residents at the end of life, yet concerns exist about the adequacy and quality of hospice care in this setting. Participants and setting: This cohort study analyzed Medicare claims data from 51,303 assisted living residents who received hospice care and died in 2018-2019. Data were linked […]

Teamwork and Use of Teams in Services for Older People: A Qualitative Study of Finnish Nurse Managers’ Experiences

Jul 1, 2025
Background: In Finnish services for older people, teams (a permanent group with a common task, divided for example by geographical or spatial criteria) have been implemented with the goal of improving the quality of care, individualized care and continuity of care as well as the wellbeing of nurses. Our aim was to describe nurse managers’ […]

Teamwork and Use of Teams in Services for Older People: A Qualitative Study of Finnish Nurse Managers’ Experiences

by Lea Efird-Green

Background: In Finnish services for older people, teams (a permanent group with a common task, divided for example by geographical or spatial criteria) have been implemented with the goal of improving the quality of care, individualized care and continuity of care as well as the wellbeing of nurses. Our aim was to describe nurse managers’ […]

The Influence of Physical, Social, and Organizational Environments on Recreational Activities in Long-Term Care for Residents With Dementia: A Scoping Review

Jul 1, 2025
Background: This scoping review explores how physical, social, and organizational factors influence recreational activity engagement for residents with dementia in long-term care settings. Methods: A literature search in AgeLine, PsycINFO, CINAHL, Medline, and Web of Science identified studies on environmental factors affecting recreational activities for long-term care residents with dementia. A narrative approach was used […]

The Influence of Physical, Social, and Organizational Environments on Recreational Activities in Long-Term Care for Residents With Dementia: A Scoping Review

by Lea Efird-Green

Background: This scoping review explores how physical, social, and organizational factors influence recreational activity engagement for residents with dementia in long-term care settings. Methods: A literature search in AgeLine, PsycINFO, CINAHL, Medline, and Web of Science identified studies on environmental factors affecting recreational activities for long-term care residents with dementia. A narrative approach was used […]

Psychometric Evaluation of the Nursing Homes Short Depression Inventory (NH-SDI) Across Long-Term Care Facilities in Lebanon

Jul 1, 2025
Background: The Nursing Homes Short Depression Inventory (NH-SDI) is an observer-reported measure used to identify depressive symptoms in older adults living in nursing homes. This study aimed to test the psychometric properties of the NH-SDI (Arabic version) in long-term care facilities (LTCF). Methods: The NH-SDI was translated to Arabic, assessed by a panel of experts, […]

Psychometric Evaluation of the Nursing Homes Short Depression Inventory (NH-SDI) Across Long-Term Care Facilities in Lebanon

by Lea Efird-Green

Background: The Nursing Homes Short Depression Inventory (NH-SDI) is an observer-reported measure used to identify depressive symptoms in older adults living in nursing homes. This study aimed to test the psychometric properties of the NH-SDI (Arabic version) in long-term care facilities (LTCF). Methods: The NH-SDI was translated to Arabic, assessed by a panel of experts, […]

Care Refusal by Older Adults With Dementia Receiving Professional Care: A Scoping Review

Jul 1, 2025
Care refusal behaviors by institutionalized older adults with dementia pose significant challenges for professional caregivers in residential care settings. This scoping review mapped the determinants and effects of care refusal in this population. A systematic search of five databases identified 19 studies published between 2013 and 2023. The findings indicated that personal, relational, environmental, and […]

Care Refusal by Older Adults With Dementia Receiving Professional Care: A Scoping Review

by Lea Efird-Green

Care refusal behaviors by institutionalized older adults with dementia pose significant challenges for professional caregivers in residential care settings. This scoping review mapped the determinants and effects of care refusal in this population. A systematic search of five databases identified 19 studies published between 2013 and 2023. The findings indicated that personal, relational, environmental, and […]

Emergency Department Discharges Following Falls in Residential Aged Care Residents: A Scoping Review

Jul 1, 2025
Background: Falls in residential aged care facilities (RACFs) have a significant impact, often leading to costly and unnecessary emergency department (ED) transfers. This scoping review examined the ED discharge proportions and patient characteristics of RACF residents presenting to the ED following a fall, to identify factors that could reduce unnecessary ED transfers. Methods: The databases […]

Emergency Department Discharges Following Falls in Residential Aged Care Residents: A Scoping Review

by Lea Efird-Green

Background: Falls in residential aged care facilities (RACFs) have a significant impact, often leading to costly and unnecessary emergency department (ED) transfers. This scoping review examined the ED discharge proportions and patient characteristics of RACF residents presenting to the ED following a fall, to identify factors that could reduce unnecessary ED transfers. Methods: The databases […]

Understanding Digital Literacy of Persons With Dementia and Their Caregivers: A Scoping Review and an Evolutionary Concept Analysis of Empirical Studies

Jun 1, 2025
WHAT THIS MEANS FOR YOU: This scoping review of 22 studies examined digitial literacy for people with dementia and their caregivers across settings and aimed to understand antecedents, attributes, and consequences of digital literacy. Support systems, and individual and sociodemographic characteristics were identified as antecedents; technological and critical thinking skills are attributes; and technology acceptance, psychosocial impacts, and digital equity were consequences. These concepts could guide the development and implementation of digital interventions for people with dementia and their caregivers.

Understanding Digital Literacy of Persons With Dementia and Their Caregivers: A Scoping Review and an Evolutionary Concept Analysis of Empirical Studies

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This scoping review of 22 studies examined digitial literacy for people with dementia and their caregivers across settings and aimed to understand antecedents, attributes, and consequences of digital literacy. Support systems, and individual and sociodemographic characteristics were identified as antecedents; technological and critical thinking skills are attributes; and technology acceptance, psychosocial impacts, and digital equity were consequences. These concepts could guide the development and implementation of digital interventions for people with dementia and their caregivers.

Optimizing Ethical Care, Quality, and Safety in Long-Term Services and Supports: A Position Paper from the American College of Physicians

Jun 1, 2025
WHAT THIS MEANS FOR YOU: This position paper examines the ethical implications of current business models and practices of long-term services and supports (LTSS) in the United States, and their effects on vulnerable populations. The paper reports four positions that would improve outcomes for vulnerable populations: optimizing care quality and incentivizing patient preferences, respecting individuals, prioritizing improvements in LTSS, and increased transparency and accountability, all of which support person-centered care.

Optimizing Ethical Care, Quality, and Safety in Long-Term Services and Supports: A Position Paper from the American College of Physicians

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This position paper examines the ethical implications of current business models and practices of long-term services and supports (LTSS) in the United States, and their effects on vulnerable populations. The paper reports four positions that would improve outcomes for vulnerable populations: optimizing care quality and incentivizing patient preferences, respecting individuals, prioritizing improvements in LTSS, and increased transparency and accountability, all of which support person-centered care.

From Nursing Homes to Home Care: Examining the Impact of the COVID-19 Pandemic on Direct Care Worker Transitions

Jun 1, 2025
WHAT THIS MEANS FOR YOU: This study examined over 8,000 direct care workers employed in residential or long-term care (LTC) communities from 2016-2018 and from 2020-2022 to examine workers' exits from LTC settings and if hazard pay mediated the impact of the pandemic. Worker exits were highest in 2020, but in 2021-2022, worker exits decreased relative to prepandemic numbers, and if workers did switch jobs, they were more likely to remain in healthcare relative to prepandemic. Hazard pay or other wage support policies did not have an effect on worker decisions to exit LTC during or after the pandemic.

From Nursing Homes to Home Care: Examining the Impact of the COVID-19 Pandemic on Direct Care Worker Transitions

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study examined over 8,000 direct care workers employed in residential or long-term care (LTC) communities from 2016-2018 and from 2020-2022 to examine workers’ exits from LTC settings and if hazard pay mediated the impact of the pandemic. Worker exits were highest in 2020, but in 2021-2022, worker exits decreased relative to prepandemic numbers, and if workers did switch jobs, they were more likely to remain in healthcare relative to prepandemic. Hazard pay or other wage support policies did not have an effect on worker decisions to exit LTC during or after the pandemic.

Artificial Intelligence in Assisted Living and Memory Care: Enhancing Care or Increasing Exposure?

May 1, 2025
WHAT THIS MEANS FOR YOU: This editorial uses data from the CAN Aging Servces Claim Report to examine how artificial intelligence (AI) can alter care, liability, and decision-making in assisted living and memory care settings.

Artificial Intelligence in Assisted Living and Memory Care: Enhancing Care or Increasing Exposure?

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This editorial uses data from the CAN Aging Servces Claim Report to examine how artificial intelligence (AI) can alter care, liability, and decision-making in assisted living and memory care settings.

A Qualitative Analysis of Safety Culture in Minnesota’s Assisted Living Facilities

May 1, 2025
WHAT THIS MEANS FOR YOU: This qualitative analysis applied the Agency for Healthcare Research and Quality's safety domains to post-2019 health inspection reports from assisted living communities in Minnesota to better understand regulation and safety. Three themes emerged in survey violations that harmed patients: staffing, compliance, and communication. Improving policies and practices related to these domains could improve safety for residents in Minnesota AL communities.

A Qualitative Analysis of Safety Culture in Minnesota’s Assisted Living Facilities

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This qualitative analysis applied the Agency for Healthcare Research and Quality’s safety domains to post-2019 health inspection reports from assisted living communities in Minnesota to better understand regulation and safety. Three themes emerged in survey violations that harmed patients: staffing, compliance, and communication. Improving policies and practices related to these domains could improve safety for residents in Minnesota AL communities.

Differences in Quality of Care Interactions Across Care Tasks in Assisted Living

May 1, 2025
WHAT THIS MEANS FOR YOU: This descriptive study of four assisted living communities in Maryland examined 152 staff-resident interactions to understand if quality of care interactions differs by care task type. Different categories of care interactions were identified with positive care interactions being the most common (36%), and supportive care being the most common type of task (34%). Supportive/ambulatory care (i.e., distracting, transferring, and walking) interactions were more negative than intimate personal care (i.e., bathing, dressing, and toileting) interactions, suggesting improvements in care interaction quality may be needed for supportive care.

Differences in Quality of Care Interactions Across Care Tasks in Assisted Living

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This descriptive study of four assisted living communities in Maryland examined 152 staff-resident interactions to understand if quality of care interactions differs by care task type. Different categories of care interactions were identified with positive care interactions being the most common (36%), and supportive care being the most common type of task (34%). Supportive/ambulatory care (i.e., distracting, transferring, and walking) interactions were more negative than intimate personal care (i.e., bathing, dressing, and toileting) interactions, suggesting improvements in care interaction quality may be needed for supportive care.

The Importance of Nature and Wishes for Nature-Based Experiences Among Older Adults in Assisted Living Facilities

May 1, 2025
WHAT THIS MEANS FOR YOU: This cross-sectional study of 25 assisted living communities in Finland examined 854 residents' views of nature-based interventions. Only 24% of residents could move outdoors independently, and only 51% had the amount of nature exposure they wanted, although 96% consider nature important and 83% stated interest in nature-based interventions. Results indicate developing nature-based interventions could be appealing for older adults.

The Importance of Nature and Wishes for Nature-Based Experiences Among Older Adults in Assisted Living Facilities

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This cross-sectional study of 25 assisted living communities in Finland examined 854 residents’ views of nature-based interventions. Only 24% of residents could move outdoors independently, and only 51% had the amount of nature exposure they wanted, although 96% consider nature important and 83% stated interest in nature-based interventions. Results indicate developing nature-based interventions could be appealing for older adults.

Facility-Level Variation of Resident Loneliness in Assisted Living and Associated Organizational Context Factors: A Repeated Cross-Sectional Study

May 1, 2025
WHAT THIS MEANS FOR YOU: This Canadian cross-sectional study used quarterly data (2017-2021) from the Resident Assessment Instrument - Home Care to assess AL resident loneliness and factors associated with loneliness. At the systems level, loneliness did not change during the course of pandemic, but levels did vary between communities. Factors associated with reducing loneliness at the community level include caregiver involvement, essential visitor policies, and video calls with volunteers/spiritual leaders.

Facility-Level Variation of Resident Loneliness in Assisted Living and Associated Organizational Context Factors: A Repeated Cross-Sectional Study

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This Canadian cross-sectional study used quarterly data (2017-2021) from the Resident Assessment Instrument – Home Care to assess AL resident loneliness and factors associated with loneliness. At the systems level, loneliness did not change during the course of pandemic, but levels did vary between communities. Factors associated with reducing loneliness at the community level include caregiver involvement, essential visitor policies, and video calls with volunteers/spiritual leaders.

Empowering Family Care Partners to Optimize Delirium Care for Persons Living with Dementia

May 1, 2025
WHAT THIS MEANS FOR YOU: This qualitative study interviewed twelve family care partners from an assisted living community in Virginia and a memory care clinic in Georgia to gain insight into intervention development for delirium superimposed on dementia (DSD). Themes such as education, proactive strategies, and empathetic communication emerged as relevant for improving outcomes for people with DSD. The study highlights the need for interventions targeting education and the mental and emotional needs of care partners.

Empowering Family Care Partners to Optimize Delirium Care for Persons Living with Dementia

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This qualitative study interviewed twelve family care partners from an assisted living community in Virginia and a memory care clinic in Georgia to gain insight into intervention development for delirium superimposed on dementia (DSD). Themes such as education, proactive strategies, and empathetic communication emerged as relevant for improving outcomes for people with DSD. The study highlights the need for interventions targeting education and the mental and emotional needs of care partners.

Inactivity Is Isolation: Insights from a Sedentary Time Intervention in Assisted Living

Apr 1, 2025
WHAT THIS MEANS FOR YOU: This exploratory study included 18 residents across three Canadian assisted living facilities who participated in a 12-week intervention to promote active aging. In post-intervention focus groups, 5 themes emerged: intervention effectiveness, physical and social engagement work together, influence of congregate living environment, environment supporting relationships, and personal preferences. The intervention was considered feasible and acceptable by participants, and could merit further testing.

Inactivity Is Isolation: Insights from a Sedentary Time Intervention in Assisted Living

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This exploratory study included 18 residents across three Canadian assisted living facilities who participated in a 12-week intervention to promote active aging. In post-intervention focus groups, 5 themes emerged: intervention effectiveness, physical and social engagement work together, influence of congregate living environment, environment supporting relationships, and personal preferences. The intervention was considered feasible and acceptable by participants, and could merit further testing.

Differing Realities Among Assisted Living Residents With Dementia: Understanding Care Partner Responses

Apr 1, 2025
WHAT THIS MEANS FOR YOU: This analysis of 73 residents with dementia and 103 care partners from eight assisted living communities in the Atlanta area examined differing realities of residents with dementia and their care partners' responses. A qualitative analysis revealed most residents experienced confusion, which led to reality management strategies deployed by care partners. These strategies ranged from ignoring or dismissing to correcting, redirecting, or joining the resident in their reality. Factors such as type of confusion and resident/care partner characteristics influenced which strategy was deployed.

Differing Realities Among Assisted Living Residents With Dementia: Understanding Care Partner Responses

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This analysis of 73 residents with dementia and 103 care partners from eight assisted living communities in the Atlanta area examined differing realities of residents with dementia and their care partners’ responses. A qualitative analysis revealed most residents experienced confusion, which led to reality management strategies deployed by care partners. These strategies ranged from ignoring or dismissing to correcting, redirecting, or joining the resident in their reality. Factors such as type of confusion and resident/care partner characteristics influenced which strategy was deployed.

Urinary Incontinence Is an Independent Risk Factor for Nursing Home Placement among Assisted Living Residents

Apr 1, 2025
WHAT THIS MEANS FOR YOU: This retrospective cohort study used 2019-2021 Medicare data to evaluate if urinary incontinence (UI) is an independent risk factor for assisted living residents' nursing home (NH) placement. Out of 247,010 residents, 20.5% had UI, and out of the 15.7% that were placed in NH, 21.7% had UI. The study confirmed that UI is an independent risk factor associated with NH placement, indicating education and early identification/treatment of UI will be helpful for avoiding/delaying NH placement.

Urinary Incontinence Is an Independent Risk Factor for Nursing Home Placement among Assisted Living Residents

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This retrospective cohort study used 2019-2021 Medicare data to evaluate if urinary incontinence (UI) is an independent risk factor for assisted living residents’ nursing home (NH) placement. Out of 247,010 residents, 20.5% had UI, and out of the 15.7% that were placed in NH, 21.7% had UI. The study confirmed that UI is an independent risk factor associated with NH placement, indicating education and early identification/treatment of UI will be helpful for avoiding/delaying NH placement.

Understanding the Experience of Employees in Assisted Living Facilities during the COVID-19 Pandemic: A Qualitative Case Study

Apr 1, 2025
WHAT THIS MEANS FOR YOU: This study involved interviews with 29 employees at an assisted living community in Oregon to assess challenges employees faced during the pandemic. The main theme that emerged was staff's need to balance "policing" residents, their families, and themselves to comply with state COVID-19-related policies, although this was often counter to their training. This issue often led to increased stress for employees, highlighting the need for policies that support AL staff during emergencies.

Understanding the Experience of Employees in Assisted Living Facilities during the COVID-19 Pandemic: A Qualitative Case Study

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study involved interviews with 29 employees at an assisted living community in Oregon to assess challenges employees faced during the pandemic. The main theme that emerged was staff’s need to balance “policing” residents, their families, and themselves to comply with state COVID-19-related policies, although this was often counter to their training. This issue often led to increased stress for employees, highlighting the need for policies that support AL staff during emergencies.

Salutogenic Architecture, Non-Therapeutic Environments and the Health of the Elderly: A Systematic Review

Apr 1, 2025
WHAT THIS MEANS FOR YOU: This systematic review of 26 articles aimed to identify architectural elements that can achieve salutogenic (positive wellbeing) goals for older adults, and how architectural design can bring salutogenic theory to life. Physical elements such as porches, balconies, and above-grade entrances are key elements in individuals' homes, while walls were identified as key elements in assisted living communities for supporting coherence due to their role in creating a personal, distinct space for residents.

Salutogenic Architecture, Non-Therapeutic Environments and the Health of the Elderly: A Systematic Review

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This systematic review of 26 articles aimed to identify architectural elements that can achieve salutogenic (positive wellbeing) goals for older adults, and how architectural design can bring salutogenic theory to life. Physical elements such as porches, balconies, and above-grade entrances are key elements in individuals’ homes, while walls were identified as key elements in assisted living communities for supporting coherence due to their role in creating a personal, distinct space for residents.

Trends in the Use of Medicare Home Health Care among Congregate Living Residents

Apr 1, 2025
WHAT THIS MEANS FOR YOU: This cohort study examined trends in home health care (HHC) of nearly 10 million Medicare patients across congregate and non-congregate care settings between 2014-2019. Of all HHC episodes, 15.9% happened in congregate care, and traditional Medicare beneficiaries in congregate care used HHC more frequently and were more likely to use high-quality agencies than those in other settings. However, dual-eligible and minoritized populations were less likely to receive high quality HHC services.

Trends in the Use of Medicare Home Health Care among Congregate Living Residents

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This cohort study examined trends in home health care (HHC) of nearly 10 million Medicare patients across congregate and non-congregate care settings between 2014-2019. Of all HHC episodes, 15.9% happened in congregate care, and traditional Medicare beneficiaries in congregate care used HHC more frequently and were more likely to use high-quality agencies than those in other settings. However, dual-eligible and minoritized populations were less likely to receive high quality HHC services.